1. Inflexibility and Behavioral Rigidity: Symptoms of inflexibility or behavioral rigidity are often difficult to quantify, and yet often introduce some of the most disruptive chronic behaviors exhibited by children with AS and HFA. These can be manifest by minor differences in the environment (e.g., changes in location for certain activities), difficulties tolerating changes in routine, and changes to plans that have been previously laid out.
For some of these “special needs” kids, this inflexibility can lead to aggression, or to extremes of frustration and anxiety that thwart activities. Parents may find themselves “walking on eggshells” in an effort to circumvent any extreme reaction from their “fragile” child. Also, the AS or HFA child himself may articulate his anxiety over fears that things will not go according to plan, or that he will be forced to make changes that he can’t handle. Sometimes these behaviors are identified as “obsessive-compulsive” because of the child’s need for ritualized order or nonfunctional routine.
It is not known whether these symptoms are produced by disturbances in the same cortico-striatal-thalamo-cortical circuitry that is believed to produce OCD. However, the model of obsessive-compulsive disorder has suggested that use of SRI agents can be useful in ameliorating this problem. Whether the effect of SRI medications on this symptom cluster is mediated by a general reduction in anxiety, or is specific for “needs for sameness” is not known. Reports from studies of alpha-adrenergic medications (e.g., clonidine, guanfacine) also suggest a decrease in these rigid behaviors.
2. Stereotypies and Perseveration: Stereotyped movements and repetitive behaviors are a common feature of AS and HFA. As with behavioral rigidity and inflexibility, similar models for stereotypy and obsessive-compulsive disorder have been proposed. Stereotypy also may be closely related to tic disorders in which repetitive behaviors emerge from impairment in dopaminergic and glutamaturgic systems.
The treatments for stereotyped movements and perseveration closely parallel those for behavioral inflexibility, and the two clusters are often grouped together in studies of treatment effectiveness. Thus, serotonin reuptake inhibitors and alpha-adrenergic agonists may be helpful. Also, the hypothesis that dopamine may play a role suggests that dopaminergic blocking agents should be added to the possibilities. Reports from studies of olanzapine, risperidone, and ziprasidone suggest this is warranted.
3. Hyperactivity and Inattention: Hyperactivity and inattention are common in AS and HFA kids, particularly in early childhood. Differential diagnostic considerations are vital, particularly in the context of AS and HFA. Hyperactivity and inattention are seen in a variety of other disorders (e.g., developmental receptive language disorders, anxiety, and depression). Therefore, the appearance of inattention or hyperactivity does not point exclusively to ADHD. The compatibility of the child and her school curriculum is particularly important when evaluating symptoms of hyperactivity and inattention. There is a risk that a school program that is poorly matched to the child's needs (e.g., by over-estimating or under-estimating her abilities) may be frustrating, boring, or unrewarding. If the verbal or social demands exceed what she can manage, they may produce anxiety or other problems that mimic inattention or induce hyperactivity.
Virtually every variety of medication has been tried to reduce hyperactive behavior and increase attention. The best evidence at this point supports dopamine blocking agents, stimulants, alpha-adrenergic agonists, and naltrexone.
4. Anxiety: Young people with AS and HFA are particularly vulnerable to anxiety. This vulnerability may be an intrinsic feature of AS and HFA through a breakdown in circuitry related to extinguishing fear responses, a secondary consequence of their inability to make social judgments, or specific neurotransmitter system defects.
The social limitations of AS and HFA make it difficult for these “special needs” children to develop coping strategies for soothing themselves and containing difficult emotions. Limitations in their ability to grasp social cues and their highly rigid style act in concert to create repeated social errors. They are frequently victimized and teased by their peers and can’t mount effective socially adaptive responses.
Limitations in generalizing from one situation to another also contributes to repeating the same social mistakes. In addition, the lack of empathy severely limits skills for autonomous social problem-solving. For higher functioning kids on the autism spectrum, there is sufficient grasp of situations to recognize that others “get it” when they do not. For others, there is only the discomfort that comes from somatic responses that are disconnected from events and experience.
Several agents have been tried for treatment of anxiety. There is no reason to suspect that children with autism are less likely to respond to the medications used for anxiety in children without autism. Therefore, SRIs, buspirone, and alpha-adrenergic agonist medications (e.g., clonidine, guanfacine) all have been tried. The best evidence to date supports use of selective serotonin reuptake inhibitors. (Note: Kids with AS and HFA may be more vulnerable to side effects and to exhibit unusual side effects.)
5. Depression: Depression seems to be common among teens and young adults with AS and HFA. Many of the same deficits that produce anxiety may conspire to generate depression. There is also good evidence that serotonin functions may be impaired in young people with AS and HFA. The basic circuitry related to frontal lobe functions in depression may be affected. In addition, deficits in social relationships and responses that permit one to compensate for disappointment and frustration may fuel a vulnerability to depression. There is some genetic evidence suggesting that depression and social anxiety are more common among first-degree relatives of autistic kids, even when accounting for the subsequent effects of stress.
The medications that are useful for depression in “typical” kids and teens should be considered for those with AS and HFA who display symptoms of depression. Since some features of depression and autism overlap, it is important to track that the changes in mood are a departure from baseline functioning. Therefore, the presence of social withdrawal in a child with AS or HFA should not be considered a symptom of depression unless there is an acute decline from that child's baseline level of functioning.
The core symptoms of depression should arise together. Therefore, the simultaneous appearance of symptoms (e.g., decreased energy, further withdrawal from interactions, irritability, loss of pleasure in activities, sadness, self-deprecating statements, sleep and appetite changes, etc.) would point to depression.
Children and teens on the autism spectrum who display affective and vocal monotony are at higher risk for having their remarks minimized. They can make suicidal statements in a manner that suggests an off-hand remark without emotional impact. When comments are made this way, parents may underestimate them. In young people with AS and HFA, the content of such comments may be more crucial than the emotional emphasis with which they are delivered.
Drugs that are useful for treatment of depression in children with AS and HFA are serotonin reuptake inhibitors. There also may be indications for considering tricyclic agents with appropriate monitoring of ECG, pulse, and blood pressure. There are no medications that have been shown to be particularly more beneficial for depressive symptoms in children with AS and HFA. Therefore, the decision as to which ones to use is determined by side effect profiles, previous experience, and responses to these medications in other family members.
6. Aggression: Aggression is seldom an isolated problem and is particularly complex in children with AS and HFA. It is important to understand that aggressive behavior is not always associated with just one condition and can have highly varied sources. An array of theoretic models has been proposed to understand aggressive behavior in kids on the spectrum. There are promising biologic models that suggest the behavior arises from alterations in dopaminergic reward mechanisms, and cognitive models suggesting that such acts are an outcome of conditioned learning. Tantrums and physical aggression are often responses to a variety of circumstances and occur in the context of diverse emotions.
It is useful to know the circumstances preceding and following aggressive outbursts before selecting a particular medication. For instance, when aggression is a response to anxiety or frustration, the most helpful interventions target those symptoms and the circumstances that produce them rather than exclusively focusing on aggressive behavior.
Unfortunately, the request for drug treatment typically follows a crisis, and the press for a rapid, effective end to the behavior problems may not permit the gathering of much data or discussion. Nonetheless, it is NOT appropriate to “always” begin with one agent or another. Moving to a more “reliable” medication too quickly may mean that the child takes on cardiovascular, endocrinologic, and/or cognitive risks that may be otherwise avoided.
There are reports in support of using serotonin reuptake inhibitors, alpha-adrenergic agonists, beta-blocking agents, mood stabilizers, and neuroleptics for aggressive behavior. When a doctor has the luxury of time, the support of family, and collaboration with staff where the child is attending school, then a drug that is safer, but perhaps takes a longer time to work or is a little less likely to help, can be tried.
In addition to cognitive and behavioral interventions, many children and teens on the autism spectrum are helped by medications (e.g., selective serotonin reuptake inhibitors, antipsychotics, stimulants, etc.) to treat the associated problems listed above. Experts agree that the earlier interventions are started, the better the outcome. With increased self-awareness and therapy, most kids and teens learn to cope with the challenges of AS and HFA.
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